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Acute Liver Failure in Pregnancy
Abstract Number: FCH-408
Abstract Type: Case Report Case Series
Acute liver failure (ALF) is defined as acute liver injury, elevated PT/INR, and encephalopathy in previously healthy individuals. It affects 2000 adults yearly in the US. We present the case of fulminant liver failure and multisystem organ failure in an obstetric patient during 2nd trimester.
A 24 G2P1 with IUP at 22 weeks was transferred to a tertiary care facility with transaminitis, pancytopenia, and renal failure. Patient had 1 week history of nausea, vomiting and was seen by her PCP and diagnosed with a viral illness. 2 days prior to transport, she was treated for presumed severe urosepsis at an outside hospital. At the time of transfer, she was in acute renal and liver failure of unknown etiology. DDX of liver failure included sepsis, HELLP, Acute fatty liver of pregnancy, toxic ingestions (mushroom vs. acetaminophen) or other. Admission labs showed AST 7317, ALT 1752, INR 3.25. The patient was started on IV piperacillin/tazobactam, norepinephrine, and fluid replacement. Invasive lines included a PICC and a-line. Fetal demise was diagnosed and the decision was made to proceed to OR for D&E for fetal evacuation to possibly improve liver function if secondary to acute fatty liver of pregnancy.
Once in the OR, general anesthesia was induced, a central line was placed, and transfusion of platelets, FFP, and Cryoprecipitate was undertaken. Following the D&E, significant blood loss was reported, and massive transfusion was initiated. Patient required increasing vasopressor support including norepinephrine, epinephrine, vasopressin, and dobutamine. Systolic pressure could not be maintained above 60mmHg. The patient experienced flash pulmonary edema and > 1L of fluid was suctioned from lungs. Upon opening the distended abdomen, 3L of bloody ascitic fluid was suctioned out and the patient experienced cardiac arrest. After 2 rounds of CPR, there was a brief return of circulation and then PEA for > 20 rounds of CPR before the end of resuscitation and time of death. On autopsy, cause of death was determined to be sequela from acute liver failure secondary to herpes simplex virus (HSV).
Fulminant HSV hepatitis is fatal in up to 80% of cases. Prompt diagnosis and treatment is required as well as early referral for liver transplantation. Pregnant and immune compromised individuals are at higher risk of acquiring this disease. HSV hepatitis should be suspected in patients with severely elevated serum transaminases and coagulopathy in the absence of jaundice. Mucocutaneous lesions or rash are only visible in 50% of the patients. Empiric Acyclovir should be initiated in patients with acute liver failure and no other source identified. HSV induced ALF is often unrecognized until autopsy. We recommend early consideration of HSV and treatment with Acyclovir in patients with ALF in pregnancy.
1. Reuben et al. Ann Intern Med 2016;164:724-32.
2. Little et al. Hepatology 2019;69: 917-919